Abstract
Jennings L, Grossberg GT. Antipsychotics continue to have a place in the management of difficult behavior problems in patients with dementia. JAMDA 2013;14:447–449.
Prescribing antipsychotics for elderly patients with dementia has become controversial in recent years, and perhaps no clinical issue in history has inspired so much involvement from the federal government. In May of 2012 the Centers for Medicare and Medicaid Services (CMS) announced an initiative to reduce the use of antipsychotic medications in nursing homes by 15% by the end of the year. This is only the most recent governmental action seeking to improve the quality of care in nursing homes. The federal government has been vocal relative to antipsychotic prescribing in the elderly since 1987, when Congress passed the Nursing Home Reform Amendments, known as OBRA-87, a series of nursing home standards that sought to improve care and uphold patients' rights, including the right to be free of “physical or chemical restraints imposed for the purposes of discipline or convenience.” Federal and public attention was drawn to antipsychotic prescribing again in 2005 and 2008, when the Food and Drug Administration (FDA) issued “black box” label warnings regarding the increased risk of mortality associated with antipsychotic use in elderly patients with dementia. In May 2011, the Office of the Inspector General released a report regarding the prevalence of antipsychotic use in nursing homes. The report implies, among other things, that off-label prescribing of antipsychotics in elderly patients with dementia is medically inappropriate, especially in the context of a black box warning. This alarming sentiment was echoed in the lay press by the report's author, Daniel Levinson, who was quoted in The New York Times as saying that antipsychotics are “potentially lethal” and that “families and caregivers should be outraged.” Prominent organizations and individuals defended the use of antipsychotics in patients with dementia, noting that prescribing off label is a common practice and not necessarily inappropriate. They also pointed out that there are currently no FDA-approved medications for the treatment of behavioral symptoms of dementia. Unfortunately, the storm cloud of controversy had already gathered. The authors agree that antipsychotics should be prescribed cautiously, and are concerned that in this emotional climate, some clinicians might shy away from prescribing antipsychotics at all.
Shi Z, Pinnock CB, Kinsey-Trotman S, et al. Prostate-specific antigen (PSA) rate of decline post external beam radiotherapy predicts prostate cancer death. Radiother Oncol 2013;107:129–133.
In this study the authors attempted to assess the association between prostate-specific antigen (PSA) velocity (PSAV) in the first 24 months after external beam radiotherapy (EBRT) and prostate cancer–specific mortality (PCSM) and all-cause mortality. All eligible patients in the South Australian (SA) Prostate Cancer Clinical Outcomes registry were followed. Patients (n=848) were treated by definitive EBRT, with more than one PSA recorded in the two-year posttreatment. The authors calculated PSAV by linear regression. Results demonstrated that the mean number of PSA measurements in the two-year period was 4.4 (SD1.9). The median PSAVs across quartiles (Q1–Q4) were −4.17, −1.29, −0.38, and 0.20 ng/ml/year. In multivariable analysis, a U-shaped relationship was seen between PSAV and PCSM, with Q1–Q4 hazard ratios (HR) being 3.82 (1.46–10.00), 3.07 (1.10–8.58), 1.00, and 5.15 (1.99–13.30), respectively. HR for all-cause mortality in a similar model were 1.79 (1.07–2.98), 1.55 (0.93–2.59), 1.00, and 1.74 (1.04–2.90) for Q1 to Q4 respectively. A rapid PSA decline in the first year was a strong predictor of PCSM. However in the second year, PSA increase was positively associated with PCSM. The authors conclude that a rapid decline in PSA in the first year following EBRT is positively associated with PCSM, and may be a useful early indicator of the need for additional therapies.
Mou J, Paillard F, Turnbull B, et al. Qutenza (capsaicin) 8% patch onset and duration of response and effects of multiple treatments in neuropathic pain patients. Clin J Pain (epub ahead of print; doi: 10.1097/AJP.0b013e31829a4ced).
Qutenza (capsaicin) 8% patch is used to treat various neuropathic indications, including postherpetic neuralgia (PHN) and human immunodeficiency virus–associated neuropathy (HIV-AN). In this meta-analysis, the authors attempted to better describe clinical phenomena of effects of Qutenza treatment, including onset and duration of pain relief and the need for retreatments. The meta-analyses combined individual patient data (1313 participants with PHN and 801 with HIV-AN) from seven completed randomized, double-blind, controlled studies. Studies had similar designs, and all used the Qutenza patch (8% capsaicin) and a low-dose control patch (0.04% capsaicin). Results demonstrated that overall, 44% of PHN and 41% of HIV-AN patients had a 30% response, and 11% and 7%, respectively, had complete pain relief 2 to 12 weeks after treatment with Qutenza. The mean (median) onset of response to Qutenza was 3.4 (1) days for PHN and 6.5 (4) days for HIV-AN (delayed due to an initial increase in discomfort). The mean (median) duration of response after one Qutenza treatment was 5.0 (3) months. Of the patients followed up for 12 months, 40% PHN and 36% HIV-AN patients had a 30% response, and 9% and 10%, respectively, had complete pain relief from week 2 to end of follow-up. The authors conclude that Qutenza is effective in a high proportion of patients, and that in patients who respond to Qutenza, analgesia starts within a few days of treatment and lasts on average five months.
Donath E, Chaudhry A, Hernandez-Ava LF, Lit L. A meta-analysis on the prophylactic use of macrolide antibiotics for the prevention of disease exacerbations in patients with chronic obstructive pulmonary disease. Resp Med 2013 (epub ahead of print; doi:10.1016/j.rmed.2013.05.004).
Macrolides are of unique interest in preventing chronic obstructive pulmonary disease (COPD) exacerbations, because they possess a variety of antibacterial, antiviral, and antiinflammatory properties. Recent research has generated renewed interest in prophylactic macrolides to reduce the risk of COPD exacerbations. Little is known about how well these recent findings fit within the context of previous research on this subject. The purpose of this article was to evaluate, via exploratory meta-analysis, whether the overall consensus favors prophylactic macrolides for prevention of COPD exacerbations. EMBASE, Cochrane, and Medline databases were searched for all relevant randomized controlled trials (RCTs). Six RCTs were identified. The primary endpoint was incidence of COPD exacerbations. Secondary endpoints including mortality, hospitalization rates, adverse events, and likelihood of having at least one COPD exacerbation were also examined. Results demonstrated that there was a 37% relative risk reduction (RR=0.63, 95% CI: 0.45–0.87, p-value=0.005) in COPD exacerbations among patients taking macrolides compared to placebo. Furthermore, there was 21% reduced risk of hospitalization (RR=0.79, 95% CI: 0.69–0.90, p-value=0.010) and 68% reduced risk of having at least one COPD exacerbation (RR=0.34, 95% CI: 0.21–0.54, p-value=0.001) among patients taking macrolides versus placebo. There was also a trend toward decreased mortality and increased adverse events among patients taking macrolides, but these were not statistically significant. The authors conclude that prophylactic macrolides are an effective approach for reducing incident COPD exacerbations, although there were several limitations to this study, including a lack of consistent adverse event reporting and some degree of clinical and statistical heterogeneity between studies.
Kiellstrom B, van der Wal MHL. Old and new tools to assess dyspnea in the hospitalized patient. Curr Rep Heart Fail 2013 (epub ahead of print; doi: 10.007/s11897-013-0140-0).
In the assessment of dyspnea one has to take into account both the patient's experience of the symptom and clinicians' observations of breathing rates, sounds, and their effort to get a complete picture. In addition, to choose appropriate treatment, the underlying cause of dyspnea needs to be assessed. While tools for clinical evaluation of heart failure have gained great interest in research and found a place in guidelines and clinical practice, the same cannot be said for instruments to assess patient self-reported dyspnea. To date, no specific dyspnea rating tool has been recommend over another. Reports from clinical practice are lacking and large; international studies in this field are warranted. This is a good article for the review and assessment of dyspnea in any patient.
Kessel RM, Roth M, Moody K, Levy A. Day one talk: Parent preferences when learning that their child has cancer. Support Care Cancer 2013 (epub ahead of print; doi: 10.1007/s00520-013-1874-8).
The discussion that occurs between a pediatric oncologist and a family when they first learn about their child's new diagnosis of cancer is known as the Day One Talk. Few studies have addressed parent preferences when learning that their child has been diagnosed with cancer. The objective of this cross-sectional study was to assess what information parents of children with newly diagnosed cancer believe is important to learn during the Day One Talk. A survey tool based on expert opinion was created to assess parents' views of components of the Day One Talk including its content, length, and setting, as well as whether the child should be present for the initial talk and which staff should be present for the talk. Results demonstrated that 62 parents of children with newly diagnosed cancer participated. Ninety-seven percent believed that the Day One Talk is extremely important. Ninety percent believed that the word “cancer” should be used during the Day One Talk. Seventy-seven percent believed that the pediatric oncologist should provide specific numbers regarding cure rates for the patient's diagnosis. Eighty-four percent of parents do not believe that children younger than 14 should be present. The authors conclude that these results suggest that parents of children with cancer have certain preferences regarding the Day One Talk. When conducting the Day One Talk, providers should elicit parent preferences regarding these issues in order to best meet families' needs.